Filling the Unmet Need for Contraception: Can We Deliver for Young Women?

Monday, June 7th, 2010 is the opening day of the international Women Deliver Conference being held in Washington, DC. This article is based on a presentation to the conference to be made by Carmen Barroso.

When we speak about universal access to contraceptives and the huge unmet need for family planning services that exists in the world today, the image that usually comes to mind is that of poor women in Africa. Indeed, in most countries, poor women have a much higher rate of unmet need than do women with higher incomes, and in Africa, unmet need for contraception is much higher than in other regions. More than 60 percent of women of reproductive age have an unmet need for contraception in Africa.

What is frequently forgotten though, is that unmet need is high among older adolescents and young adults, and most pronounced among young women 20 to 29 years of age. From any angle we look, young women are at the greatest disadvantage in terms of access to needed services, in Africa and everywhere in the world. An estimated 818 million women worldwide would like to limit childbearing but do not have access to modern contraceptives. Nearly 70 percent of young women in sub-Saharan Africa and an equal share in Southeast and South Central Asia have unmet need for contraception. As a result of this gap, the number of unintended pregnancies and births if very high. Unintended pregnancies contribute to unsafe abortions: Adolescents account for an estimated 2.5 million of the approximately 19 million unsafe abortions that occur annually in the developing world.

These facts should give us reason enough for much greater attention to young women. There are, however, three other reasons that are as or more compelling.

The first is purely demographic: early childbearing contributes to population momentum, the neglected component of population growth. Population momentum refers to the continued population growth that occurs even after a given population growth has reached replacement-level fertility when there is a high concentration of people in their childbearing years.

In terms of population growth, an exclusive focus on fertility decline is misguided because postponement of childbearing has a significant contribution to the overall rate of growth of a population and the absolute numbers ultimately resulting from that rate of growth. Those of us coming from a rights-based perspective do not feel very comfortable discussing the demographic issues at hand because of the risk of using “population control” to justify coercive policies. The fact that a huge number of women do want to space births and limit the ultimate size of their families, though, creates a win-win situation, where fulfilling women’s own expressed needs results in a demographic bonus – not an insignificant consideration in a world increasingly pressured by environmental concerns. In short, getting to a slower rate of growth can be achieved without trampling on individual rights. Quite the opposite: it is better achieved by fulfilling young women’s right to information, to health services and to autonomy regarding the decision on whether and when to have children and how many children to bear.

The second reason why we should pay more attention to young women’s unmet need is that fulfilling their needs has proved more difficult than is the case with older women. Throughout the world, we have seen that in cases where fertility rates have declined substantially among women above 30 years of age, the same has not always happened among younger women despite similar desires to space and limit births . In fact, the proportion of adolescents who have become mothers in Latin America has actually increased in 14 countries and decreased in only 3 of the 17 countries studied, even when the adolescent fertility rate has slightly decreased due to the fact that there was a decrease in second births.

The explanation for this intractability of unmet need among adolescents rests on a host of different social conditions in different countries. In many societies, lack of educational opportunities and economic inequalities offer few attractive options to girls other than motherhood. This is especially true for girls living in poverty. A substantial proportion of adolescent mothers declare that their pregnancy was desired even though this proportion seems to be decreasing –at least in the countries in Latin America. But an equally substantive proportion –both married and unmarried– wanted to postpone or avoid pregnancy.

A third and pervading factor that affects both wanted and unwanted pregnancies of adolescents in most societies is the basic question of young people’s sexual rights.

This might be surprising because when we think of unmet need the first thing that comes to mind is supply of contraceptives and availability of services. And indeed, they are basic. Without contraceptives, women of any age will – by and large – be unable to realize their own desire to avoid a pregnancy or to limit the size of their families to that desired. The same applies to young women. Married and unmarried adolescents alike need information and access to contraceptive methods so that they can avoid a pregnancy they do not want. But young women face deep social and psychological barriers that older women normally don’t. And they all have their roots in the denial of young women’s sexual rights.

In most societies there is a deep resistance to recognize young people as subject of rights, and an equality strong denial of the recognition of them as sexual beings. The deadly combination of these entrenched values takes different shapes and forms in different cultures and different societies. While in some places young women are forced into early marriages with the expectation that they produce sons whether or not they want to do it, in others good girls are still expected to remain virgins until marriage no matter how late that might occur.

Cultures are rapidly evolving and public policies could successfully address the violation of human rights evident in harmful cultural practices. However, of greatest concern is that very little public policy support exists for programs that address young people’s sexuality in an evidence-based and non-judgmental way even in societies where enforcement of virginity taboos is rapidly eroding or is no longer as prevalent.. Good quality comprehensive sexuality education is very rarely available in schools, much less for the millions of adolescents who are out of school. Rigorous studies have shown that comprehensive sexuality education works but resources for its large-scale implementation are far from the top of the agenda, even for those trying to address unmet need. Youth friendly services remain a boutique endeavor.

Equally or perhaps even more damaging is the other side of the coin: the feeling of lack of entitlement to education and services among young women. The lack of society’s recognition of their sexual rights and the absence of public policies to fulfill those rights makes it inconceivable for many of them to use services that might be available and used by older women.

So, what is the advocate for meeting the unmet need to do? Push for continuing strong endorsement of the Millennium Development Goal 5 b at all relevant international fora? Yes. Keep adolescent fertility as the most important indicator among those related to 5b? Yes. Advocate for resources earmarked to young women’s services and education? Yes. Advocate for gender-sensitive comprehensive sexuality education is schools? Yes. Support policies to empower young women economically? Absolutely! But above all, promote the sexual rights of young women, their full recognition as rights bearers, according to their evolving capacity.

The future is now, folks: You can get an abortion by videoconference. It’s not quite as crazy as it first sounds — these are non-surgical abortions — but, still, it is a pretty tremendous way to improve access to basic medical care. Planned Parenthood clinics in Iowa are the first and only ones to match women in rural areas far removed from any abortion providers with a doctor who can prescribe the drug mifepristone by webcam, the New York Times reports. Patients still undergo a thorough examination by a nurse, live and in-person, before they meet their virtual doctor. “Then, with a click of his mouse, a modified cash register drawer pops open in front of the woman” with the drugs inside, says the Times.

“One way or another, we’re going to shut this scheme down,” Mr. Newman of Operation Rescue said. “Health care just isn’t a one-size-fits-all package of pills. And yet there it is — prearranged, prepackaged, out pops that package of pills — pop!”

Particularly considering that Mr. Newman promotes laws that require doctors to read ProLife scripts written by State legislators and provide ‘one-size-fits-all’ abortion care regardless of the effect on the woman being treated or the reason why she is getting the abortion. Has anyone read one of these laws to see if there is an exception in cases where the abortion is for the purpose of removing a dead fetus? I think it would be pretty upsetting to view the ultrasound and listen to the finger and toe count then.